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December 2016 Texas Medicaid Provider Procedures Manual

Medical Transportation Program Handbook : 2 Individual Transportation Provider (ITP) : 2.3 Claims Filing for ITPs

2.3
To file a claim, an ITP completes the H3017 form that was sent to the Medicaid client and mails is to TMHP at the following address:
Texas Medicaid & Healthcare Partnership
Claims
PO Box 200555
Austin, TX 78720-0555
The H3017 includes the following transportation details:
The H3017 claim form must be signed by the doctor, dentist, or drug store representative that rendered services to the MTP client. This signature stands as proof that the ride authorized by MTP was taken. The ITP must also sign the claim form and include the API and TPI that was assigned to them by TMHP. If any of this required information is missing, the claim will be denied.
The provider must mail the completed claim form to TMHP after the client’s authorized ride, but no later than 95 days from the date of the ride. Any claims received by TMHP more than 95 days after the date of the ride will be denied.
An ITP may not charge an MTP client a fee for completing claim forms. TMHP also cannot be charged for the filing of claim forms.

Texas Medicaid & Healthcare Partnership
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